HIV vulnerabilities and psychosocial health among young transgender women in Lima, Peru: results from a bio‐behavioural survey

Abstract Introduction Peruvian young transgender women (YTW) ages 16−24 years are a critical but understudied group for primary HIV prevention efforts, due to sharp increases in HIV prevalence among TW ages 25 years and older. Methods Between February and July 2022, a cross‐sectional quantitative study with YTW ages 16−24 years in Peru (N = 211) was conducted consisting of a bio‐behavioural survey accompanied by laboratory‐based testing for HIV and sexually transmitted infections (STIs). Bivariate and multivariable Poisson regression models were used to estimate prevalence ratios between socio‐demographic and behavioural characteristics and HIV status. Results HIV prevalence was 41.5% (95% CI: 33.9−49.4%), recent syphilis acquisition 19.4% (95% CI: 12.7−28.4), chlamydia 6.3% (95% CI: 3.1−11.1) and gonorrhoea 12.3% (95% CI: 7.9−18.7). Almost half (47.9%) reported condomless anal sex in the past 6 months, 50.7% reported sex work in the past 30 days and 13.7% reported accepting more money for condomless sex. There were no significant differences in reported sexual behaviours by HIV status. Only 60.8% of participants reported ever having been tested for HIV, and 25.6% reported a past 6‐month STI test. More than two‐thirds (67.8%) had not heard of antiretroviral pre‐exposure prophylaxis (PrEP) and only 4.7% had taken PrEP in the past month. Current moderate‐to‐severe psychological distress was endorsed by 20.3%, 10.0% reported attempting suicide in the past 6 months and 85.4% reported alcohol misuse. Conclusions Findings show that the HIV epidemic for YTW in Lima, Peru is situated in the context of widespread social exclusion, including economic vulnerabilities, violence victimization and the mental health sequelae of transphobic stigma that starts early in life. Future research should aim to further understand the intersection of these vulnerabilities. Moreover, there is an urgent necessity to design and evaluate HIV prevention programmes that address the root systems driving HIV vulnerabilities in YTW and that focus on developmentally specific clusters of stigma‐related conditions.


I N T R O D U C T I O N
Globally, transgender women (TW) are at high risk for HIV acquisition with an estimated HIV prevalence, through a metaanalysis combining available international data, of 19.1%, a nearly 50-fold increased odds of HIV compared to the general population [1].In Peru, TW are most affected by HIV, with a prevalence of 20.8−29.8%,measured in Lima and other cities of the country between 2009 and 2016 [2,3], compared with 0.2−0.3% in the general population [3].Young TW (YTW) ages 16−24 years are a critical group for primary HIV prevention efforts in Peru, due to sharp increases in HIV prevalence among TW ages 25 years and older, increasing four times the odds of HIV acquisition compared to the group 18−20 [2].Biological risk factors associated with HIV transmission in TW include sexually transmitted infections (STIs) and condomless receptive anal sex [4,5].However, data are needed on HIV co-occurrence with other STIs, and HIV risks specifically among YTW in Peru.Additionally, HIV risk for TW occurs in the context of widespread stigma and social exclusion, such as employment discrimination often associated with engagement in sex work, and internalization of transphobic mistreatment [6,7].Consequently, HIV acquisition is only one of the multiple stigma-related health conditions that TW face [9].The extent to which YTW in Peru are burdened by stigma, mental health (e.g.psychological distress, post-traumatic stress disorder) and other psychosocial risks (e.g.gender-based violence, alcohol misuse) remains largely unknown [9,10].
Vulnerability for HIV in YTW occurs during the crucial developmental milieu of adolescence and young adulthood [11].YTW navigate developmental tasks common to all youth (e.g.autonomy) [12].They must also contend with tasks specific to being a transgender youth that may increase HIV risk [13] such as transgender identity disclosure (e.g.family, peers, romantic relationships), youth-specific stigma exposures (e.g.transphobic bullying), and lack of youth-and trans-friendly healthcare (e.g.HIV/STI biomedical prevention testing and treatment).Mental health and psychosocial vulnerabilities may co-occur and synergistically potentiate risk for HIV in YTW [14] influencing bio-behavioural HIV prevention goals such as protected sex and pre-exposure prophylaxis (PrEP) indication [9].Consequently, it is critical to characterize these vulnerabilities to design developmentally specific stigma-related programmes that effectively mitigate HIV risks.Nonetheless, data regarding YTW and the HIV epidemic are still scarce in Peru and in Latin America [15].
Reducing HIV inequities for TW globally will require early HIV prevention efforts focusing on TW developmental risks uniquely occurring during adolescence and young adulthood.This paper characterizes the prevalence of HIV and other STIs, identifies structural and psychosocial vulnerabilities for HIV, and estimates the correlates of HIV status among YTW in Lima, Peru.

Participants
Between February and July 2022, a cross-sectional quantitative study was conducted with 211 YTW ages 16−24 in Peru consisting of a socio-demographic, psychosocial and sexual risk behaviour survey accompanied by laboratory-based testing for HIV, syphilis, gonorrhoea, chlamydia, hepatitis B and C. Eligibility criteria included identifying as a transgender woman, being age 16−24 years and residing in Lima.Being a transgender woman was defined as a person assigned a male sex at birth who identifies on the transfeminine continuum regardless of the initiation or completion of any medical gender affirmation procedures.

Community engagement
This study was informed by a formative qualitative research phase described elsewhere [16].The qualitative phase of the study informed aspects of the study such as operating hours, incentives and duration of the survey.In addition, the study protocol was presented to Feminas, a community-based organization formed and led by TW in Lima, to elicit community feedback on its feasibility and acceptability.

Recruitment and study sites
Participants were recruited via leaders or recruiters from a community-based organization, and through peers.Participants who completed the study were also asked to refer potential participants to their social network to enhance the diversity of participants and expand recruitment.Six study offices were placed in six different districts giving the study wide coverage of metropolitan Lima.A fieldwork team was formed consisting of two survey interviewers, a laboratory technician and one counsellor.Survey interviewers were TW in their early 20s.

Measures
Survey measures were drawn from prior research with TW populations [17][18][19].The interviewer-administered survey explored socio-demographic characteristics including age, educational level, region of birth, ethnic ancestry, work and employment, and monthly income.Medical gender affirmation was asked including hormone use, surgical procedures and industrial silicone injection ("silicone fillers") for feminization.The questionnaire explored sexual behaviours such as sexual role (insertive, receptive, both), number of partners in the last 6 months, condomless sex, engagement in sex work and acceptance of money for not using condoms in sex work using measures from prior research with TW.Experiences of violence were assessed by asking about physical, psychological or sexual violence (ever and in the past 3 months) and transgender-specific intimate partner violence, conceptualized as transphobic violence perpetrated by an intimate partner (e.g."Did your partner tell you or threaten to tell someone else that you are transgender against your will, in order to humiliate you or to make you feel unsafe?") [20].
The questionnaire also explored psychological distress using the six-item Kessler-6 psychological distress tool [21], posttraumatic stress disorder using the five-item Primary Care Post-Traumatic Stress Disorder (PTSD) Screen for DSM-V post-traumatic stress disorder symptoms, suicidal thoughts and attempts [22], and alcohol misuse (using the AUDIT-C score) [23].Healthcare access was measured by assessing if the person had medical insurance, access to HIV/STI testing, PrEP awareness and use, and anticipated discrimination using the Intersectional Discrimination Index [24].The final survey instrument was designed to take approximately 60 minutes to complete.

Procedures
Study staff explained the study process to eligible participants and obtained written consent before the face-to-face administration of the survey.

Data analysis
Proportions and 95% confidence intervals (95% CI) were estimated for binary and categorical variables of interest, while medians and interquartile ratios were estimated for continuous variables.Demographic, behavioural and biological outcome variables were analysed in relation to HIV status as the outcome of interest.Results are presented for the total study population that completed the survey as well as among only those participants who completed HIV testing.Bivariate analysis was conducted using chi-squared tests for all variables except when the observed count was less than five, in which case a Fisher's exact test was used.

Sample characteristics
Out of 218 potential participants screened, 211 TW enrolled in the study and 164 (77.7%) gave blood samples for HIV/STI testing.There were no significant differences between those who completed HIV/STI testing and those who did not regarding socio-demographic characteristics, self-reported HIV status and previous HIV testing (Table S1).However, participants who gave a blood sample were significantly more likely to report engaging in recent condomless sexual activity (p = 0.02) and having multiple sexual partners (p = 0.02) (Table S1).
Table 1 presents socio-demographic characteristics overall and by HIV status among participants who completed HIV/STI testing.The median age of participants was 23 years (minimum 16, maximum 24).Approximately half of the participants (52.1%) were born outside of Lima, 72.0% of the participants had completed secondary school or higher and 18% reported currently being in school.Regarding ancestry, 34.1% of participants self-identified as mixed (mestizo), followed by indigenous Amazonian (27.0%) and Afro Peruvian (12.3%).Most participants reported having an informal job (63.1%), while 33.6% reported being unemployed.Among the 71 unemployed participants, 27% were currently in school.There were no significant differences in HIV status between participants currently in school compared to those who were not currently in school.The majority of the study population (68.3%) reported earning under 1500 soles (US$ 410) per month.There were no significant differences in socio-demographic characteristics by HIV status.

HIV and STIs
Table 2 shows the prevalence of HIV and other STIs.HIV prevalence was 41.5% (95% CI: 33.9−49.4%).Of the 68 participants testing HIV positive, 79% (n = 54) self-reported being HIV negative or not knowing their HIV status.As displayed in Figure 1

Psychosocial characteristics
Psychosocial characteristics of the sample are displayed in ever using hormones, 20.9% ever injecting silicone and 15.2% having had at least one surgical procedure.

Mental health and violence experiences
The majority of participants (61.6%) reported experiencing violence at some point in their lifetime (psychological, physical or sexual) and 21.3% reported experiencing violence in the past 3 months (Table 4).Transgender-specific intimate partner violence was reported by 24.6% of participants, with 18.5% of participants reporting experiences in the past 3 months.Regarding current mental health, 19.9% endorsed moderate to severe psychological distress and 20.4% PTSD symptoms.
Approximately one in four (23.7%) reported ever attempting suicide and 10.0% reported attempting suicide in the past 6 months.Alcohol misuse was found in 64.0% of participants (Table 4).The most common type of violence experienced over the lifetime was psychological violence (56.4%), followed by physical violence (44.5%) and sexual violence (26.1%).
For healthcare access (Table 4), most participants reported having medical insurance (46.0%public insurance, 30.3% private).Only 60.2% of participants reported ever participating in HIV testing, and only 25.6% reported an STI test in the past 6 months.The majority of participants (68.7%) had not    parability.The trend of increasing HIV prevalence across age found in this study, which may indicate cumulative effects of vulnerability, suggests the potential impact of earlier intervention.
Our results highlight that the HIV epidemic for YTW in Lima, Peru is situated in the context of widespread stigma and social exclusion, including economic vulnerabilities, violence victimization and the mental health sequelae of transphobic stigma that starts early in life.
YTW in this sample experienced constrained educational and economic opportunities.More than half of participants reported sex work in the last 30 days to support themselves economically.Lifetime and recent experiences of violence were common, including psychological, physical and sexual violence.
Although the population reached in this study is not representative of the whole YTW population, our findings parallel the conditions of marginalization and exclusion that we described in adult TW in Peru more than a decade ago [2].The Peruvian legal framework does not recognize the gender identity of transgender people, which is an obstacle to accessing basic rights such as health, education or work [27].Furthermore, other public policies protecting the rights of transgender people are almost non-existent in the country [28].
This paper reports transphobic violence including transgender-specific intimate partner violence, building on previous literature among Peruvian adult TW [29].Previous studies have shown gender-based discrimination to be positively associated with HIV acquisition among TW in Brazil [25], and several studies around the world have described a similar context of violence and marginalization [30][31][32].
More than one-quarter of YTW sampled experienced a lifetime traumatic event, and current PTSD symptomatology was high.The mental health context surrounding HIV also included suicidality, with one in four participants reporting a suicide attempt in their lifetime, a high prevalence of current psychological distress and alcohol misuse.Findings underscore the urgent need to develop and assess comprehensive mental health support and programmes tailored to the specific needs of YTW, to address the complex interplay between mental health challenges, HIV vulnerability and overall wellbeing.
Approximately half of the sample reported condomless receptive anal sex conferring sexual HIV acquisition or transmission risk.HIV and STI testing uptake were suboptimal and situated alongside more than one-third of the sample reporting anticipated discrimination in healthcare settings.Experiences of discrimination can prevent access to health services, including HIV prevention and care [8,33].Two-thirds of the sample had never heard of PrEP and uptake was extremely low (4.7%).
Few statistically significant differences were found between YTW by HIV serostatus.Engaging in sex work itself was not associated with HIV positivity.However, accepting more money for condomless sex during sex work was associated with an HIV-positive serostatus in an age-and educationadjusted multivariable model.Sexual and economic exploitation, situated within widespread transmisogyny and violence, can render YTW at an extreme structural disadvantage resulting in the imperative to accept more money for condomless sex during sex work [5][6][7].
These findings indicate an immediate opportunity and need for early programme efforts to address the HIV epidemic among YTW in Peru.In 2016, the Peruvian Ministry of Health approved guidelines to provide integrated and genderaffirming care for TW, as part of HIV care programmes [34].Nonetheless, it has not yet been adopted by most health establishments, and in some facilities, it stopped after the COVID-19 pandemic [35].
The new HIV prevention guidelines for key populations in Peru include the provision of PrEP out of cost in primary care facilities, which started in November 2023 [36].Though the scale-up of PrEP provision is promising, access to services among TW is a bottleneck to widespread coverage of interventions [37].A previous PrEP implementation study conducted in Brazil, Mexico and Peru showed challenges with engagement and adherence to PrEP among TW, fostered by constrained access to services and mistrust of health institutions [38].In our study, 39% of participants had never tested for HIV.Additionally, 79% of those who tested positive for HIV during the implementation self-reported being HIV negative or not knowing their HIV status before participating.
Structural interventions tackling broader determinants of health, such as guaranteeing protective legal frameworks (e.g.gender identity laws), labour inclusion programmes or food assistance initiatives for people living in extreme poverty, have shown to be feasible and to potentiate access to health services among transgender people in countries of the region like Argentina or Uruguay [34].Moreover, our results underscore the need to design and evaluate strategies that integrate health provision with other protection systems focused on youth, gender-based violence and discrimination against gender minorities.
There are several limitations of this study.First, this was a convenience sample of YTW recruited through peer networks and may not be representative or generalizable to all YTW in Peru.Second, this was a cross-sectional study so findings are associational only and causality cannot be inferred.Third, the median age of participants was 23 and few YTW ages 16−17 years were sampled; thus, findings may overrepresent those ages 18−24 years.However, the study demonstrates a substantial unmet need for biomedical HIV prevention and the ability to recruit a vulnerable youth sample underserved by current HIV prevention efforts and in need of public health initiatives.Future research is needed to reach younger age TW and girls, including methodological research on how to reach the youngest age groups, particularly given the high burden of HIV and STI co-occurrence already seen in the current sample and the need for early intervention.

C O N C L U S I O N S
The HIV burden among Peruvian YTW sampled was alarmingly high.Findings show the multiple mental health and psychosocial vulnerabilities faced by YTW that can intersect to fuel HIV vulnerability and STI co-morbidities in YTW and need to be further studied.Furthermore, these findings emphasize the necessity to design and evaluate programmes addressing the root systems driving HIV vulnerabilities in YTW.To protect rights and wellbeing, initiatives should strengthen edu-

Figure 1 .
Figure 1.Proportion of participants testing positive and negative for HIV by age group.

Table 3
presents the sexual behaviours of participants, overall and

Table 1 . Characteristics of young transgender women in Lima, Peru, overall and by HIV status
p-values of the comparison of proportions between participants who tested HIV positive and HIV negative.
aOne participant was missing age data.+

Table 4
. The median age of self-acknowledgement of gender identity was 13 (IQR: 8−16).Approximately half of the sample (52.7%) were not "out" about being trans in all aspects of their lives.Regarding medical gender affirmation, 49.8% reported

Table 3 . Recent sexual behaviour by HIV status among young transgender women in Lima, Peru All participants Participants who completed HIV testing
+ p-values of the comparison of proportions between participants who tested HIV positive and HIV negative.

Table 4 . (Continued)
aMissing n = 11 (5.2%).b Defined as breast implants, face/neck surgery or genital surgery.c Only among participants, self-reporting HIV negative or HIV status unknown (n = 147).+ p-values of the comparison of proportions between participants who tested HIV positive and HIV negative.